Journal of Bodywork & Movement Therapies 37 (2024) 38–45

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Effects of hypopressive exercises on pelvic floor and abdominal muscles in

adult women: A systematic review of randomized clinical trials
Carolina Miqueleto Santoro Katz a, *, Carmem Patrícia Barbosa b
a
Physical Education Professional, University of Maringá, Maringá, Paraná, Brazil
b
Department of Morphological Sciences, State University of Maringá, Paraná, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Hypopressive exercises (HE) are postural and breathing exercises that activate deep muscles in the
Breathing exercises abdomen and pelvic floor. Despite this, there is still no consensus in the literature on its real effectiveness. The
Postural exercises objective was to analyze the effects of HE on the abdominal and pelvic floor muscles in women with or without
Urinary incontinence
dysfunctions in these regions.
Pelvic organ prolapse
Methods: This is a systematic review of randomized clinical trials found in the PEDro, PubMed, Cochrane, LILACS,
and Embase databases. We include studies that evaluate the effects of HE (with or without other techniques) on
the pelvic floor and abdominal region for 8 weeks or more, in women over 18 years old, with or without
dysfunction in these regions, with the presence of a control group (active or passive).
Results: HE were effective in improving strength, tone, and reducing symptoms of pelvic floor dysfunctions, in
magnitude less than (in two studies) or equal (in one study) to the pelvic floor muscle training (PFMT). When HE
were performed with PFMT in the same group, no additional benefits were found. Only one study evaluated
abdominal muscles activation, where HE were effective in improving postural control and activation of the
transversus abdominis muscle.
Conclusions: The HE presented positive results to the evaluated parameters. However, the information is still
preliminary and scarce. There are methodological divergences regarding the execution, follow-up and stan­
dardization of the method, which could affect the results. According to the existing information, HE cannot yet be
reliably indicated for the treatment of the pelvic floor, despite pointing out relevant results in some studies. More
randomized clinical trials and long-term studies are needed to analyze the effects of HE not only for pelvic floor,
but also for other regions, such as abdominal muscles and related dysfunctions.

1. Introduction dysfunctions, and pelvic pain (Grimes and Stratton 2020), abdominal
diastasis and weakness in the abdominal muscles, (Reinpold et al., 2019;
The abdominal region and the pelvic floor together form the largest Jessen et al., 2019). Due to these possible complications and considering
visceral cavity in the body. The abdominal and pelvic floor muscles the relationship between these muscles/regions, authors describe the
provide important functions such as support and protection of the importance of adequate strengthening (Norton and Brubaker 2006;
anatomical structures of the digestive and urinary systems, as well as the Akhtar et al., 2017). There are several types of physical exercise mo­
internal reproductive organs. These muscles allow access to the internal dalities (Monteiro and Evangelista 2010; Ochoteco and Soledad 2011; Li
reproductive and urinary organs, perform important accessory functions et al., 2016; Hayden et al., 2005), among which are currently the HE.
in breathing, defecation, urination, vomiting, laughter, support the The HE were created by Marcel Caufriez in 1984 with the aim of
weight of the body, stabilize the spine and ensure movements (Moore providing urogynecological rehabilitation, improving the conditions of
et al., 2014). the pelvic floor, especially in women in the postpartum period, and
The abdominal and pelvic floor muscles can present several dys­ seeking to strengthen the abdomen, without harming the pelvic floor
functions that affect more and more women, such as pelvic organ pro­ (Rial et al., 2011). Also known as Hypopressive Abdominal Gymnastics,
lapse (POP), urinary incontinence (UI), fecal incontinence, sexual these exercises consist of postural and breathing techniques that, by

* Corresponding author.
E-mail addresses: carolina.ms.katz@gmail.com (C.M.S. Katz), carmemmec1@gmail.com (C.P. Barbosa).

https://doi.org/10.1016/j.jbmt.2023.03.003
Received 5 April 2022; Received in revised form 7 March 2023; Accepted 20 March 2023
Available online 24 August 2023
1360-8592/© 2023 Elsevier Ltd. All rights reserved.
C.M.S. Katz and C.P. Barbosa Journal of Bodywork & Movement Therapies 37 (2024) 38–45

relaxing the diaphragm and activating the inspiratory muscles, decrease We excluded studies with men, children, pregnant, women up to six
intra-abdominal pressure and provoke reflex activation of the pelvic months postpartum, women who underwent surgical intervention for
floor, abdominals, and other stabilizing muscles of the spine, increasing pelvic reconstruction.
the tone of these muscles (Caufriez et al., 2006; López and Villalobos The included studies should present an intervention group that
2018). practiced only HE, or HE plus other techniques for rehabilitation/pre­
Previous studies claim that the abdominal and pelvic floor muscles vention of dysfunctions in the abdomen and pelvic floor. The studies
are activated during HE practice (Stüpp et al., 2011; Ithamar et al., should also present an active control group (using some exercise for the
2018). Considering the close relationship and activation synergy be­ pelvic floor or abdomen) or a passive one (not performing any specific
tween these musculatures, the large number of women affected by exercise for these regions).
dysfunctions in these regions, and the popularity of this new rehabili­ We only included studies that evaluated the effects of HE for at least
tation method, it is relevant to understand its possible effects on this eight weeks, which we considered in this study to be a medium-term
population and these muscles. Thus, this systematic review aims to effect. Studies that assessed immediate effects during and shortly after
analyze the effects of HE on the abdominal and pelvic floor muscles in HE were excluded (peri- and post-immediate period).
women with or without dysfunctions in these regions.
2.3. Assessment of study quality
2. Methods
We used the Pedro scale to analyze the quality of the included
2.1. Research strategy and data source studies. This scale evaluates randomized clinical trials in 11 items. The
first does not score (regards external validity), and the other 10 score
This is a systematic review study conducted in accordance with the according to the internal validity and statistical information of the
Preferred Reporting Items for Systematic Reviews and Meta-Analyzes included studies (score from zero to 10).
(PRISMA). To identify the articles, an initial search in the PubMed, LI­ We describe the relevant limitations of the included studies, found by
LACS, PEDro, Embase and Cochrane databases was performed using the the authors of this review or cited by the studies themselves (Table 1).
word “hypopressive” in all databases, to make the search more
comprehensive, until March 4, 2023. There was no language limitation. 2.4. Data extraction and synthesis
Articles were selected first by title and abstract, and those with po­
tential for inclusion were separated for full reading. Two independent We extracted data from the included articles and divided them into
authors carried out the entire process of search, selection and inclusion three tables:
of the studies. In case of disagreement, inclusion was resolved between
the same two authors. Information about the inclusion process is present 1) Study design, methodological quality according to the PEDro scale
in PRISMA flowchart (Fig. 1). (score from 0 to 10) and limitations of the studies (Table 1);
2) Participants, HE protocols, technical fundamentals of HE, descrip­
2.2. Inclusion criteria tion of respiratory patterns of HE (Table 2);
3) Intervention, variables studied, evaluation methods, results of the
We included only randomized clinical trials that evaluated the effects group that performed the HE, the conclusion of the study (Table 3).
of HE on the abdomen or pelvic floor, either for strengthening the
muscles or reducing symptoms/treating dysfunctions in these regions.
Participants were women over 18 years old, symptomatic or asymp­
tomatic (with or without dysfunctions in the abdomen and pelvic floor).

Fig. 1. PRISMA search strategy flow chart.

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C.M.S. Katz and C.P. Barbosa Journal of Bodywork & Movement Therapies 37 (2024) 38–45

Table 1 studies (Molina-Torres et al., 2023; Moreno-Muñoz et al., 2021; Nav­

Methodological quality of included studies. arro-Brazález et al., 2020; Soriano et al., 2020), and for 12 weeks in
Author, year Study PEDro Limitations three other studies (Bernardes et al., 2012; Jose-Vaz et al., 2020;
design Scale Resende et al., 2019). The frequency was two or three times a week for a
Molina-Torres et al., RCT 6b,d The lack of follow up in long term period of 20–40 min; however, some studies did not describe this in­
(2023) formation (Resende et al., 2019; Bernardes et al., 2012). The practice of
Moreno-Muñoz et al., RCT 8 Control group did not perform any HE in four studies was entirely under the supervision of a trained pro­
(2021) exercise, short intervention period fessional (Jose-Vaz et al., 2020; Molina-Torres et al., 2023; Mor­
Navarro-Brazález RCT 8 Short intervention period
et al., (2020)
eno-Muñoz et al., 2021; Soriano et al., 2020). However, in other two
Jose-Vaz et al., (2020) RCT 6a,c The lack of follow up in long term studies, the professional only followed the first three sessions and, after
Soriano et al., (2020) RCT 7b Control group did not perform any this period, the participants practiced the HE alone, at home, and
exercise without supervision during the sessions (Bernardes et al., 2012; Resende
Resende et al., (2019) RCT 8 Short intervention period, no
et al., 2019). Only one study used both forms: professional follow-up
follow-up with a professional
throughout the study (twice a week) plus daily and home exercises (Navarro-Brazález et al.,
Bernardes et al., RCT 6a,d No follow-up with a professional 2020) (Table 2).
(2012) throughout the study

RCT = randomized clinical trial. 3.3. Results of included studies

a
assessor was not blinded.
b
the allocation of subjects was not blind. In general, all articles showed that HE were effective in improving
c
measurements of at least one key outcome in less than 85% of subjects pelvic floor muscle strength and tone, reducing UI and POP symptoms,
initially distributed. as well as improving postural control parameters and transversus
d
data indicating initial similarity between prognostic indicators are not clear. abdominis muscle activation. The studies that compared HE with a
passive control group reported improved pelvic floor muscle tone and
3. Results decreased symptoms of UI in the group that performed HE (Soriano
et al., 2020; Molina-Torres et al., 2023).
3.1. Selection of included studies Among the three studies comparing HE versus PFMT, one concluded
that HE is as effective as PFMT to improving strength, tone, and symp­
In our initial search of the databases, we identified 170 articles. After toms of pelvic floor dysfunction (Navarro-Brazález et al., 2020). The
exclusion of duplicates, 46 studies were selected for screening. Of these, other two concluded that PFMT is more effective than HE for improving
32 were excluded because they were not randomized clinical trials, two pelvic floor muscle strength, reducing UI episodes and POP symptoms
included men, two were not found, two were congress abstract/journal (Jose-Vaz et al., 2020; Resende et al., 2019). The studies that evaluated
supplement, and one had the intervention with less than eight weeks of HE plus PFMT did not find additional benefits when compared to the
HE practice. In the end, we included 7 studies in this review (Fig. 1). PFMT technique alone or HE alone for strength and activity of the pelvic
floor muscles, increase in the cross-sectional area of the levator ani
3.2. Characteristics of the included studies muscle and improvement of symptoms of pelvic floor disorders (Ber­
nardes et al., 2012; Navarro-Brazález et al., 2020).
Among all studies, 587 women were included in this review, 462
with some pelvic floor dysfunction and 125 healthy. Except for one 3.4. Limitations of included studies
study (Moreno-Muñoz et al., 2021), all others included participants with
UI or POP (Table 1). Publication years range from 2012 to 2023. We describe the quality assessment and limitations of the studies
Only one study aimed to analyze the effects of HE on abdominal included in Table 1. In this study, topics five (blinding of the subjects in
muscles (Moreno-Muñoz et al., 2021). All other articles included analyze the study) and six (blinding of the physiotherapists who administered
the effects of HE on the pelvic floor muscles or symptoms of dysfunction the techniques) of the PEDro scale received a "no" answer in all studies,
in this region, comparing it with passive control groups or pelvic floor as blinding is not possible during these interventions. Thus, the
muscle training (PFMT). maximum score achieved by the studies would be eight. Of the seven
The experimental and control groups of the included studies were articles included, three scored 8 (Moreno-Muñoz et al., 2021; Nav­
composed as follows. arro-Brazález et al., 2020; Resende et al., 2019), one scored 7 (Soriano
et al., 2020) and three scored 6 (Bernardes et al., 2012; Jose-Vaz et al.,
• Three studies compared a group with HE alone versus a passive 2020; Molina-Torres et al., 2023). We considered the following items as
control group, which did not perform any activity (HE vs. passive limitations of the studies (some of them cited by the authors of the
control group) (Moreno-Muñoz et al., 2021; Soriano et al., 2020; studies).
Molina-Torres et al., 2023);
• Two studies compared HE versus PFMT (HE vs. PFMT) (Jose-Vaz - Lack of follow-up in long term (Jose-Vaz et al., 2020; Molina-Torres
et al., 2020; Resende et al., 2019); et al., 2023);
• One study compared HE versus PFMT, and a third group performed - Short intervention period (despite being included for performing the
both techniques together (HE vs. PFMT vs. PFMT + HE) (Navarro-­ HE for at least 8 weeks) (Moreno-Muñoz et al., 2021; Resende et al.,
Brazález et al., 2020); 2019; Navarro-Brazález et al., 2020);
• One study compared PFMT versus a group that practiced PFMT plus - Passive control group: studies that included control groups that did
HE, and a third passive control group (PFMT vs. PFMT + HE vs. not perform any type of exercise (Soriano et al., 2020; Moreno-
passive control group) (Bernardes et al., 2012). Muñoz et al., 2021);
- No follow-up with a professional supervision throughout the study:
The variables studied for the pelvic floor were strength, tone, muscle the participants performed the HE without professional monitoring
activity, morphological changes, and symptoms of disorders such as UI during the sessions (Bernardes et al., 2012; Resende et al., 2019).
and POP. Regarding the abdominal muscles, the variables were postural
control and deep trunk muscle function (Table 1).
In the protocols, the HE were performed for eight weeks in four

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C.M.S. Katz and C.P. Barbosa Journal of Bodywork & Movement Therapies 37 (2024) 38–45

Table 2
Characteristics of the included studies.
Author, year Participants HE protocols Technical fundamentals Description of respiratory patterns of HE

Molina-Torres et al., 117 women with PFD (>6 Duration of 8 weeks, 2 - Axial elongation, “Rib cage proprioception, apnea familiarization,
(2023) months) times per week, 20 min, - Neutral pelvis, center of gravity projection, and abdominal vacuum”
supervised training - Ankle dorsiflexion,
- Activation of the shoulder girdle
Moreno-Muñoz 125 women aged 18–60 Duration of 8 weeks, 2 - Autoelongation; “Three breath cycles repetitions were performed
et al., (2021) years times per week, 30 min, - Double chin; with each posture, and the patients changed
supervised training - Decoaptation of the glenohumeral joint; their posture during the expiration maneuver”;
- Neutral pelvis; “nasal inspiration with rib opening”; “total
- Dorsal ankle flexion; exhalation, apnea maintained with a costal
- Gravity shaft overrun; opening: closure of the glottis, voluntary
- Lying supine with legs bent/lying with contraction of the serratus majors and muscles
alternating legs flexion/sitting/cat of the upper airway, intercostals, scalenes, and
position/kneeling, standing/standing sternocleidomastoid, diaphragm relaxation and
without support/standing with trunk cavity pressure reduction”
flexion and hand resting on the knee
- Arm position variants (on the hips or on the
chest)
Navarro-Brazález 94 women with PFD (IU e Duration of 8 weeks, 2 - Standing, kneeling, four-point kneeling, “Exhaling to their expiratory reserve volume,
et al., (2020) POP) aged 18–70 years times per week, 45 min, sitting and supine positions, using a variety then holding their breath (apnea), and
supervised training þ of upper and lower limb positions expanding their rib cage, to draw their
daily exercises at home abdominal wall inward and cranially without
inhalation”
Jose-Vaz et al., 90 women with IU and an Duration of 12 weeks, 2 - Neutral pelvis and spine elongation; “Three breathing cycles with lateral-costal
(2020) average age of 56.9 years times per week, 50 min, - Ankle dorsiflexion; breathing and slow deep exhalation
to HE group and 53.4 supervised training - Knee flexion; (inspiration, maximum exhalation);
years to PFMT group - Activation of the shoulder girdle muscle; maintenance of breathing after rib-cage
- Lying supine with legs bent/lying with expansion (diaphragmatic aspiration)”
alternating legs flexion/sitting with legs in
front and standing against the wall/cat
position/kneeling, standing without
support/standing with trunk flexion and
hand resting on the knee
- Arm position variants (on the hips, on the
chest or above the head)
Soriano et al., 42 women with IU aged Duration of 8 weeks, 3 - Neutral pelvis; “Three breathings and exhalations, apnea with a
(2020) 20–65 years times per week, 30 min, - Self-alongation of the spine; rib cage opening and axial stretch”
supervised training - Head in a double chin position;
- Knee flexion;
- Inclination plane;
- Standing position/kneeling/quadruped/
Mohammedan prayer/seated/supine/sumo
position (trunk inclined with hands support
on knees);
- Arm position variants (extension, on the
hips, on the chest or above the head)
Resende et al., 61 women with POP II Duration of 12 weeks, 40 - In supine and standing positions “Slow, diaphragmatic inspiration followed by
(2019) min, daily exercises at total exhalation and, after a glottal closure, a
home gradual contraction of the abdominal wall
muscles, with superior displacement of the
diaphragm cupola (diaphragmatic aspiration)”
Bernardes et al., 58 women with POP II Duration of 12 weeks, - In lying down and standing positions Not described
(2012) session time not
described, daily
exercises at home

HE = hypopressive exercise; PFMT = pelvic floor muscle training; PFD = pelvic floor dysfunction; UI = urinary incontinence; POP II = pelvic organ prolapse grade II.

4. Discussion this review show that HE were able to improve postural control, acti­
vation of the transversus abdominis muscle, strength, tone and resis­
Currently, there is growing public and clinical interest in HE, but tance of the pelvic floor muscles, and reduce symptoms and severity of
evidence is still scarce to support their benefits (Martín-Rodríguez and pelvic floor dysfunction, such as IU. .Compared to PFMT, in relation to
Bø, 2019). Three systematic reviews found in the literature cited HE, the evaluated parameters, HE showed results equal (in one study) or
which analyze only their effects on the pelvic floor. Only one of them inferior (in two studies) to the first technique.
focused exclusively on the effects of HE, including articles only up to Six included studies evaluated variables related to the pelvic floor,
2017 (Ruiz de Viñaspre Hernández 2018), while the other two aimed to comparing HE with passive control groups or with the PFMT. When
analyze various rehabilitation methods (Mateus-Vasconcelos et al., compared to the passive control groups, the HE were effective and
2018; Jacomo et al., 2020). showed significant results to the pelvic floor function (tonus and
This systematic review aimed to present and discuss the effects of HE strength) and dysfunction symptoms such as IU (Molina-Torres et al.,
on the abdominal and pelvic floor muscles, alone or with other tech­ 2023; Soriano et al., 2020). When comparing the HE with the PFMT, one
niques. It is important to highlight that this is the first systematic review study concluded that both groups presented similar results for increased
that analyzes, exclusively through randomized clinical trials, the effects strength, tone, and reduced symptoms of pelvic floor dysfunction
of HE for eight weeks or more in these muscles/regions. The results of (Navarro-Brazález et al., 2020). Another two stated that PFMT was

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C.M.S. Katz and C.P. Barbosa Journal of Bodywork & Movement Therapies 37 (2024) 38–45

Table 3
Outcomes of the included studies.
Author, year Intervention Studied variables Evaluation methods Results of the groups with the presence of Conclusion
HE

Molina-Torres Randomized PFM strength, genital Modified Oxford Improvement in the pelvic floor muscle HE were effective in improving
et al., (2023) participants in two prolapse symptoms, Scale and strength, a significantly lower score for PFM contractility, and reducing
groups (1-HE e 2- colorectal symptoms, questionnaires (PFIQ7, the PFIQ7 total score and FPDI20, symptoms associated with PFD,
PCG) and symptoms of UI FPDI20, ICIQ-SF) improvement in ICIQ-SF values such as urinary incontinence
Moreno-Muñoz Randomized Posture control and Stabilometric platform; Positive effects on the surface of the area, HE were effective in improving
et al., (2021) participants in two deep trunk muscle real-time ultrasound the anteroposterior displacements, and postural control parameters and
groups (1-HE e 2- function imaging the velocity of the Center of Pressure transversus abdomini activation
PCG) movement variables; Improvement of
transverse abdominal muscle during
voluntary contraction
Navarro-Brazález Randomized Strength, tonus, PFIQ-7; PFDI-20; Improved strength and tone and reduced The three groups were effective
et al., (2020) participants in three symptoms of PFD vaginal palpation; symptoms of PFD without significant differences
groups (1- PFMT; 2- manometry; between them
HE; 3- PFMT + HE) dynamometry
Jose-Vaz et al., Randomized Symptoms of UI, ICIQ-SF; vaginal Reduction of urinary leakage episodes, PFMT was superior than HE
(2020) participants in two strength palpation; manometry improvement of quality of life and regarding to number of urinary
groups (1- HE e 2- strength leakage episodes, perceived
PFMT) impact of SUI in quality of life
and PFM strength.
Soriano et al., Randomized Tonus and symptoms Manometry; ICIQ-SF Improvement of tone and UI symptoms HE were effective in improving
(2020) participants in two of UI in the experimental HE group PFM tone and decreasing UI
groups (1- HE e 2- symptoms compared to the PCG
PCG)
Resende et al., Randomized Strength, muscle P-QoL; POP-Q; vaginal Improvement in strength, electrical The PFMT group was superior
(2019) participants in two activity, symptoms of palpation; SEMG activity, quality of life, prolapse severity, to the HE group in all
groups (1- HE e 2- POP POP symptoms and pelvic floor muscle parameters
PFMT) function
Bernardes et al., Randomized Cross-sectional area of POP-Q; two- Increase in LA cross-sectional area Similar effective for LA cross-
(2012) participants in three LA, symptoms of POP dimensional sectional area
groups (1-PFMT; 2- transperineal
HE + PFMT; 3- PCG) ultrasonography.

PFD = pelvic floor dysfunction; PFM = pelvic floor muscle; UI = urinary incontinence; SUI = stress urinary incontinence; POP II = pelvic organ prolapse grade II; PFMT
= pelvic floor muscle training; HE = hypopressive exercises; PCG = passive control group; BIO = biofeedback exercises; ELEC = transvaginal electrical stimulations,
LA = levator ani muscle; SEMG = surface electromyography; MRI = static magnetic resonance imaging, PR = puborectalis; IL = iliococcygeus.

superior to the HE in the evaluated parameters (UI and POP symptoms, with the practice of a hypopressive gymnastics program to improve
pelvic floor muscle strength and quality of life) (Jose-Vaz et al., 2020; symptoms of dysfunctions in the pelvic floor, but in no case should they
Resende et al., 2019). be considered a complete treatment for the pelvic floor (Caufriez, 2016).
Researchers cite the relevance of knowledge about the specificities of Some articles describe not finding significant changes in the cross-
the muscles and the characteristics of the exercises applied to them, sectional area of the levator ani muscle during HE maneuvers and
especially in rehabilitation (Juez et al., 2019). The pelvic floor muscles, insufficient muscle activation to generate strength gains (Navarro
such as the levator ani muscle, are formed mostly by type I fibers, which Brazález et al., 2020b; Resende et al., 2016). According to evidences,
are responsible for maintaining muscle tone, posture, supporting pelvic strength is not the only important variable when evaluating the pelvic
viscera, and aiding continence involuntarily. The smallest part is floor, as dysfunctions such as UI can be related to other parameters, such
composed of type II fibers, generating greater levels of muscle tension as fatigue or delayed muscle responses (Arbieto et al., 2021; dos Santos
during intense strength activities (Moore et al., 2014; Ross, 2012; Koelbl et al., 2019; Smith et al., 2007; Roza et al., 2015). Several authors claim
et al., 1989). that isolated voluntary contraction of the pelvic floor muscles improves
HE activates the abdominal and pelvic floor muscles reflexively, as the ability to bear weight in the face of increases in intra-abdominal
their techniques are primarily postural and respiratory, decreasing intra- pressure, preventing further disturbances in this region (Hyland et al.,
abdominal pressure, relieving overload, and increasing tone in these 2014; Dumoulin and Hay-Smith, 2010; Kovoor et al., 2008; Thompson
regions (Caufriez et al., 2006; Osorio and Caufriez, 2018; Rial et al., and O’Sullivan, 2003). However, authors suggest that a training pro­
2011; Rial and Pinsach, 2015; Rial and Villanueva, 2012). The PFMT is gram for the pelvic floor muscles should consider, in addition to strength
consolidated in the literature as a ’gold standard’ method for the reha­ training, postural exercises (tonic activation), as a focus on postures and
bilitation of pelvic dysfunctions, mainly UI and POP, as it involves breathing patterns are important in the rehabilitation protocols (Smith
muscle-strengthening exercises through voluntary contractions of the et al., 2007; Hodges et al., 2007; Sapsford and Hodges 2001). Never­
pelvic floor (Bø, 1995; Dinubile, 1991; Hay-Smith and Dumoulin, 2006; theless, in the included studies, performing HE plus PFMT did not seem
Li et al., 2016; Plevnik et al., 1986; Wilson et al., 2002). to bring additional benefits when compared to the group that practiced
Therefore, these two exercise modalities (PFMT and HE) may PFMT only (Bernardes et al., 2012; Navarro-Brazález et al., 2020).
generate different activations in the pelvic floor muscles, making it A preliminary study by Juez et al. (2019), which evaluated women
difficult to compare them, even though the objective of the practices is from the third postpartum month onwards, found positive results for
similar. The HE could not act with the same magnitude on type II fibers, pelvic floor muscles regarding strength, tone and response to stretching
directly involved in the greater strength gain and hypertrophy in the for both the PFMT and HE groups, suggesting higher improve for HE in
pelvic floor (Morley et al., 1996). Perhaps, for this reason, some studies levator muscle thickness and satisfaction. The same study describes that
did not find such expressive results for HE when compared to PFMT HE could be interesting for the treatment of postpartum women. Indeed,
(Jose-Vaz et al., 2020; Resende et al., 2019; Stüpp et al., 2011). The this population have weaknesses in the pelvic floor and it takes time to
creator of this technique, Marcel Caufriez, states that there are benefits recover muscle function (Bø et al., 2022).

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C.M.S. Katz and C.P. Barbosa Journal of Bodywork & Movement Therapies 37 (2024) 38–45

Evidences indicate that many women have difficulty to voluntarily included mention this respiratory maneuver, the creator of the method,
contracting the pelvic floor or perform a strong contraction in these Caufriez (2016), in his book, states that diaphragmatic aspiration with
muscles (Devreese et al., 2004; Dietz et al., 2001; Fitz et al., 2020; Talasz opening of the ribs should only be used in some cases, such as to improve
et al., 2008; Thompson et al., 2006). Studies have demonstrated, in venous return or decreased intra-abdominal and pelvic floor pressure.
different populations, other ways of working the pelvic floor, such as For him, this breathing practice cause relaxation of the abdominal and
through breathing exercises and activation of the deep abdominal pelvic floor muscles, and would not be interesting when the goal is
muscles, but they are still scarce (Hung et al., 2010; Tavahomi et al., strengthening. This information goes against the protocols used in the
2023; Zachovajeviene et al., 2019; Zivkovic et al., 2012; Talasz et al., studies of this review, and needs to be tested in detail in future studies.
2022). Indeed, guidelines for conservative management of pelvic floor Finally, many points discussed in this review are important for future
disorders mention that the abdomen is a neglected subject (Nambiar studies in the area. First, it is necessary to standardize the HE guidelines,
et al., 2018; Qaseem et al., 2014). Sapsford (2004) stated that specific so the studies can be reproducible and compared to each other, taking
training of the transversus abdominis muscle could be effective for into account the correct postural and respiratory bases. Second, a
pelvic floor rehabilitation. In fact, authors claim that there is a synergy comparison between HE and PFMT or other methods that involve
between the muscle contraction activities of the abdomen and pelvic voluntary contraction of the pelvic floor, must be done with caution,
floor in women with and without pelvic floor disorders (Laycock, 1994; considering the specificities of the techniques and their possible
Sapsford, 2004; Sapsford and Hodges, 2001; Vesentini et al., 2019). different influences on the muscles (such as muscle fibers). Third, as it is
Studies have identified this synergistic muscles in healthy nulliparous a postural and respiratory method, studies that evaluate the effects of HE
women during HE maneuver (Ithamar et al., 2018; Stüpp et al., 2011), on abdominal and respiratory parameters are topics of great importance
confirming that during this method abdomen and pelvic floor are and are scarce in the literature. Four, randomized clinical trials with
reflexively activated (Rial et al., 2011; Rial and Villanueva, 2012). longer intervention time and follow-up should be performed (compared
As in the pelvic floor, the abdominal muscles have a greater number to PFMT or any other technique).
of type I fibers, as these muscles have relevant functions of postural For some authors, HE are still under development (Martín-Rodríguez
maintenance and containment of internal viscera (Häggmark and and Bø, 2019; Juez et al., 2019). Thus, more research is needed to un­
Thorstensson, 1979). Breathing and postural exercises, as well as those derstand this technique and its possible effects in the context of muscle
that work the core muscles in different ways, are used for abdominal prevention and rehabilitation.
strengthening (Lee et al., 2015), even showing better results than This review presents some limitations, such as the exclusion of recent
traditional abdominal exercises (Cavaggioni et al., 2015). Presenting postpartum women, as they have important dysfunctions in the
these same characteristics, HE promotes the activation of the abdominal abdomen and pelvic floor regions. The intervention and control groups
muscles (Rial et al., 2011; Armesilla and Andrés, 2014) and could pre­ were distinct between studies, making it difficult to comparisons.
sent satisfactory results in relation to the dysfunctions involved in this However, a strength of this review was to highlight relevant points in the
region. However, although some studies with HE are emerging and discussion regarding the descriptions of HE and the existing divergences
indicate improvements in parameters related to chronic non-specific low about them, raise questions regarding the specific differences in muscle
back pain (decreasing pain, increasing mobility, improving disability, action of HE and PFMT, and highlight the importance of new studies
quality of life and thickness of the diaphragm) (Bellido-Fernández et al., focusing on other effects of this technique, besides those related to the
2022; Vicente-Campos et al., 2021), and good results in the treatment of pelvic floor.
abdominal diastasis (Arranz-Martín et al., 2022; Ramírez-Jiménez et al.,
2021), information is still scarce and new studies, mainly randomized 5. Conclusion
clinical trials, must be carried out. In this review, due to the inclusion
criteria, only one study specifically evaluated the abdomen, showing We conclude that HE showed positive results for strength, tone and
good results in the group that practiced HE (Moreno-Muñoz et al., symptoms of pelvic floor dysfunction in women. However, until now, HE
2021). cannot be indicated as a reliable treatment for the pelvic floor, because
Authors discuss the importance of follow-up and supervision to despite presenting similar results to PFMT in one study, others show that
perform pelvic floor exercise programs (Price et al., 2010; Zanetti et al., PFMT continues to be superior. Studies with HE are still scarce in the
2007). Despite this, studies claim that both supervised and literature and show divergences of patronization in its execution. In
non-supervised PFMT technique are effective for improving pelvic floor spite of this, the HE point to promising results that must be proven in
muscles parameters (Felicíssimo et al., 2010; Kharaji et al., 2023). In further studies. PFMT and HE should be compared with caution due to
contrast, for HE, the absence of continuous follow-up seems to be an their training specifics and possible distinctions regarding muscle acti­
important limitation during practices for clinical populations without vation. Clinical trials with long intervention periods and follow-up
prior knowledge of the technique (Rebullido and Chulvi-Medrano, should be performed, comparing HE with PFMT or any other tech­
2019), but this statement needs to be confirmed by future studies. In niques. The HE were beneficial for improving the activation of the
this review, two studies cite the practice of HE performed by the par­ transversus abdominis muscle and postural control, but only one study
ticipants alone, daily in their homes, with only three initial classes with focused on these variables. Therefore, further studies are needed to
instruction from a professional (Bernardes et al., 2012; Resende et al., assess the effects of HE on the prevention and rehabilitation of disorders,
2019). not only in the pelvic floor, but mainly in the abdominal region, focusing
In the included studies, there were divergences about the technical on muscular, postural and respiratory parameters.
descriptions of HE breathing maneuvers. Some studies cite the instruc­
tion of total exhalation of air (Jose-Vaz et al., 2020; Moreno-Muñoz Clinical relevance
et al., 2021; Resende et al., 2019). However, according to Rebullido and
Chulvi-Medrano (2019), full exhalation of air is considered a wrong way • The HE showed positive effects concerning strength and tone of the
to perform HE. The standardization of expiration is important because a pelvic floor muscles, a decrease in symptoms of UI and POP, but so
total exhalation maneuver is related to greater activation of the deep far, we cannot claim that they are superior to PFMT or that it would
abdominal muscles, which may affect the results when compared to a be a reliable method to treat dysfunctions in the region.
normal expiration (Ishida and Watanabe, 2013, 2015; Yoon et al., • Only one study included evaluated the effects of HE on abdominal
2014). muscles, showing positive results in muscle activation. Therefore,
Another relevant point of divergence was found in the definitions future studies in this area are needed.
and execution of diaphragmatic aspiration. While all the studies

43
C.M.S. Katz and C.P. Barbosa Journal of Bodywork & Movement Therapies 37 (2024) 38–45

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the creator of the technique. Filho, A.L., 2010. Intensive supervised versus unsupervised pelvic floor muscle
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trial. International urogynecology journal 21 (7), 835–840. https://doi.org/
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